Provider First Line Business Practice Location Address:
1930 S BROAD ST
Provider Second Line Business Practice Location Address:
UNIT 5
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-467-5870
Provider Business Practice Location Address Fax Number:
215-467-5873
Provider Enumeration Date:
11/16/2006